Provider Demographics
NPI:1457336042
Name:MARLEY, KIM R (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:R
Last Name:MARLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 OLD FARM LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3646
Mailing Address - Country:US
Mailing Address - Phone:814-243-3365
Mailing Address - Fax:
Practice Address - Street 1:438 OLD FARM LN
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3646
Practice Address - Country:US
Practice Address - Phone:814-243-3365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425474208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101222472Medicaid
PA1691647OtherHIGHMARK BLUE CROSS
PAF79886Medicare UPIN
PA089488Medicare ID - Type UnspecifiedMEDICARE